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SANJOAQUIN Environmental Health Department <br /> -- COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTrFEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S ) EXPIRES 180 DAYS FROM THE APPROVAL DATE . DO NOT WRITE IN ANY SHADED AREAS . <br /> INDICATE PERMIT TYPE : <br /> Eg REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT I PHONE# <br /> FACILITY NAME 7-Eleven #20632 IPHONE # <br /> ADDRESS 4627 Da Vinci Drive , Stockton , CA 95207 <br /> CROSS STREET <br /> OWNER OPERATOR7-Eleven Inc. Stephen Boyd PHONE # 714-771 -5484 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME L . C . Services PHONE # 559-444 - 1730 <br /> CONTRACTOR ADDRESS 3887 N . Valentine Ave . CA LIC # 779267 CLASS A , B, C , Haz <br /> INSURER ACE American Insurance Company WORKER COMP# RWCC48829521 <br /> FIRE DISTRICT Stockton Fire Department PERMIT # BP17-06844 <br /> LABORATORY NAME Test America COUNTY PHONE # 615-726-0177 <br /> SAMPLING FIRM stantec PHONE # 619865-5847 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAS DATE INSTALLED <br /> 39- 0517938 10 , 000 87 Unleaded 4/ 1 / 1998 <br /> 39 - 0527939 10 , 000 91 Unleaded 4/ 1 / 1998 <br /> 39 - <br /> 39 - <br /> 39 - <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , FEDERAL LAWS , AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT' S SIGNATURE CERTIFIES THE <br /> FOLLOWING : " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. " CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING : RTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WOR S CO PENSATION LAWS OF CALIFORNIA.' <br /> APPLICANT' S SIGNATURE TITLE L . C . Services DATE 11 i � <br /> ❑ APPROVEDAPP OVED WITH CONDITION ( S ) El DISAPPROVED <br /> IS OND IONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER' S NAME DATE "kd <br /> ANY DEVIATIONS FROM THIS APLIC ION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK , <br /> CONDITIONS : <br /> 3 of 10 <br />